What is anorexia nervosa?
Anorexia nervosa has become an epidemic in the field of mental health in the last five decades . This disease has presented a spectacular incidence and has become a real challenge for health systems, especially in the most developed countries.
Anorexia nervosa concept.
Perhaps it is convenient to clarify that when in this article we refer to anorexia nervosa or anorexia / bulimia we are not referring to the medical symptom of anorexia , understood as a lack of appetite and that can appear throughout the life of a subject in multiple everyday circumstances and in pathological states, such as feverish symptoms, gastrointestinal diseases, infectious problems, etc.
The use of the term anorexia in this article will always be aimed at describing an eating disorder . We adopt Mayo Clinic terminology when describing anorexia:
“… Is an eating disorder characterized by abnormally low body weight, intense fear of gaining weight, and distorted perception of weight. For people with anorexia, it is very important to control their weight and body shape, and they make all kinds of sacrifices that often interfere with their life significantly. (Minnesota Mayo Clinic, 2018).
The importance of anorexia , in recent years, is determined, not only by the unstoppable escalation of cases , which has made this disorder a true sociocultural phenomenon, but by the scarce therapeutic results obtained, especially when compared with other of the main pathologies with the highest prevalence today.
The true fact of the high incidence in the last fifty years forces us to reflect on the differences between cases of classic anorexia and the cases that currently affect a good part of the adolescent female population. These differential features will be discussed later.
Anorexia and bulimia.
When it comes to unifying the terminology, we say that there are two types of anorexia: restrictive anorexia and anorexia with bingeing and purging.
Although anorexia and bulimia appear as two different conditions typified by the DSM-5 within eating disorders, in this monograph we will not make an express differentiation of them, except in certain chapters such as the response to pharmacological treatment, where we will make an express differentiation.
We thus join some authors who see a continuity between anorexia and bulimia :
“… The symptoms often appear as a continuum between those of anorexia nervosa and those of bulimia nervosa. Patients with anorexia may alternate between restrictive and bulimic periods at different stages of their evolution. And among the bulimic type of anorexia nervosa are those who purge or vomit after a binge and those who only vomit or purge without bingeing ”. (Dio Bleichmar, E. 2000).
The American Psychiatric Association (APA) itself recognizes this continuity between anorexia and bulimia:
“Concern about weight and an overvaluation of silhouette and thinness are equally present in anorexia as well as in bulimia, and most patients present a combination of bulimic and anorexic behaviors.” (Practice Guideline, Am. J. Psychiatry, 2000).
There is no doubt that around anorexia / bulimia, from the first descriptions of the picture, there is a notable conceptual confusion, the result of visions that have only focused on partial aspects such as motivations, the pathogenesis of the disease or symptoms.
Anorexia nervosa as a heterogeneous entity.
It is important not to generalize when speaking of anorexia as if it were a homogeneous entity. It is a picture that can occur in neurotic personalities, in borderline personalities and in psychotic personalities.
In the last decades of the 20th century, studies of systemic family therapy began to speak of the family of the anorexic. This conception of the “family of the anorexic” enjoyed a great popularity among the scientific class, but today it is clearly outdated.
Anorexia can be caused by different motivations and also by different types of families, by different types of mothers or fathers.
An important aspect, which we will see in more detail when discussing the causes and consequences of anorexia, is that anorexia is the consequence of another underlying disorder. Anorexic symptoms are the expression and consequence of another disorder, which they cover up. This fact is not disputed today and is supported by both the psychodynamic currents and the American Psychiatric Association itself in its guide to eating disorders.
Anorexia and motivational systems.
This aspect outlined above is of great importance when it comes to analyzing the motivational systems that underlie anorexia, since a correct assessment of the participation of these motivational systems will largely determine the effectiveness of psychotherapy by being able to act on the elements of the genesis and perpetuation of the disease.
If we apply the Modular-Transformational Approach to the study of anorexia (Bleichmar, 1997) as a model to understand the subjective processes of adolescents, we can observe a complex relationship between the various motivational systems that interact in anorexia: narcissistic, sensual- sexual, attachment, hetero-self-preservation and psychobiological regulation.
We will try in this study to analyze those factors that intervene in the genesis of anorexia and we will see how they should be taken into account at the time of an approach through a dynamic psychotherapy that takes into account the Modular-Transformational Approach.
We will now take a brief historical tour of anorexia. We will analyze the diagnosis of the disease and then we will focus on the characterological features and the factors that are most frequently associated with anorexia. When speaking of associated traits, we are not saying that they are always present in all cases of anorexia, but rather that they appear in anorexia with a statistically significant correlation.
In these character traits lies the importance of studying the particular personality of each specific patient, since each subject has specific variants, which will allow us to do a psychotherapy focused on specific distinctive traits for that particular patient.
Anorexia nervosa throughout history.
Although anorexia has become a first-rate social health problem since the end of the 20th century, anorexia was already known in ancient times and we can find various testimonies, which confirm this.
Ahora bien, al seguir las huellas de este trastorno a lo largo de los siglos no debemos caer en el error de identificar anorexia nerviosa con delgadez. En la actualidad estamos acostumbrados a escuchar la palabra “anorexia” de forma generalizada, masiva e indiscriminada. Cualquier persona con un peso corporal por debajo de la media es etiquetada como “anoréxica”. Sin embargo, dicho término encierra mucho más significado del que se le atribuye en la sociedad actual. Se trata de “un trastorno con alteraciones a nivel psicológico y nutricional, caracterizado por una disminución de la ingesta que es lo que conlleva a la disminución del peso corporal”. (García de Castro, S. 2014).
La anorexia en la antigüedad.
El ayuno voluntario ha existido desde el principio de la historia; sin embargo, no siempre ha sido interpretado como un síntoma de enfermedad o trastorno, si no que más bien era concebido como un tipo de conducta religiosa. En muchos casos era un ejemplo de castidad y pureza religiosa.
Ya los antiguos egipcios practicaban el ayuno antes de entrar en sus templos sagrados como símbolo de purificación (Chinchilla 2003). Y ciertas tribus africanas prescindían del alimento para ceder éste a los hijos (Almenara 2003).
En la obra de Hipócrates se encuentran claras alusiones a cuadros compatibles con la anorexia.
Claudia Octavia, la primera mujer de Nerón, murió de una enfermedad semejante a la anorexia.
Bulimia appeared in Roman times through the great parties that involved compulsive eating for entire days, where vomiting was almost essential to continue with those banquets.
The Greek doctor Galen already described “kinos orexia” or canine hunger as a synonym for bulimia in the second century , being considered as a consequence of an abnormal state of mind. In the Talmud we also find references to bulimia.
The Middle Ages: The Holy Anorexia.
In the Middle Ages, anorexia appears linked to religious values that color the entire culture of the time. Religious fasting is understood as a penance, as a form of spiritual elevation, where the soul prepares itself for its encounter with God.
“The flesh was to be dominated; the spirit had to triumph ”. (Toro, J. 1996).
On the other hand, fasting was also interpreted as a form of asceticism, since it was associated with visions and direct contact with God; therefore, the fasting women of these centuries were considered saints and their survival without food was a miracle of God, which led to their canonization. This type of food restriction has been called “Santa Anorexia.”
The history of the Catholic Church is dotted with cases of anorexia that led its protagonists to canonization. Thus we can see the cases of Santa Librada, who gave herself up to fasting after being raped by a Saracen king. Others, like Saint Wilgefortis, fasted and asked God that her thinness drive away her suitors. Saint Catherine of Siena, after several years of fasting, died with just over 20 kilos of weight. Our Saint from Avila, Teresa de Jesús was an expert in making herself vomit. To this endless list, Sor Juana Inés de la Cruz or Santa Liduvina de Chiedam can be added. (Barrera, A. 2016).
In all cases, anorexia is the path chosen to mortify the body and please God.
From santas to witches.
Al empezar la Edad Moderna, en los siglos XV y XVI, las mujeres que sobrevivían sin alimento empezaron a ser concebidas como brujas en lugar de santas y su destino pasó de ser la canonización a ser la quema en la hoguera o el exorcismo.
“La importancia de conocer el motivo del ayuno radicaba en determinar si éste era obra de Dios o del demonio, en vez de darle la importancia merecida a la salud”. (Doyen, C. y Cook-Darzens, S. 2005).
La anorexia en los hombres.
But throughout history, there have not only been fasting girls. Some men have also practiced fasting. For example, the English poet Lord Byron, after being an obese teenager, exaggeratedly restricted his diet and practiced intense physical exercise, becoming an example to follow for many adolescent girls of the time. Another example was the Austro-Hungarian writer Franz Kafka, who described himself as “the slimmest man I know” and was eating an excessively restrictive diet and practicing intense physical exercise.
First descriptions of anorexia.
Beginning in the 17th century, advances in science made female fasters attract the attention of physicians. They wanted to see if survival without food due to God’s miracle or demonic work was true and possible. It was at these times that symptoms and behaviors that all these women had in common were determined.
In 1689, the English physician Sir Richard Morton, described in detail for the first time anorexia nervosa, which was then called ” nerve wasting “. This is how Morton describes that experience:
“I do not remember having seen any living being so degraded and with such a degree of wasting, but he did not have a fever, but on the contrary a considerable cold in his body. […] He only showed a lack of appetite, and poor digestion, with frequent fainting spells ”.
However, it seems that in the year 1500 Simone Porta had already observed a clinical case that can be identified with the picture of anorexia.
In 1873, the French psychiatrist Ernest Charles Lasègue published an extensive treatise on the disease, which he calls “hysterical anorexia.” Thus, he defined the disease as a hysteria or nervous disorder associated with a digestive disorder.
At the same time as Lasègue, the English royal court physician, William Withey Gull, published a comprehensive treatise in which he defined this disease as an eating disorder and called it “anorexia nervosa.”
One of the diagnostic criteria for anorexia nervosa currently included in the DSM-5 is fear of gaining weight as a reason for restricting food intake. It is curious that until 1889 this aspect was not mentioned in the medical literature. It was the French neurologist Jean Martin Charcot who pointed out this important diagnostic criterion .
Almost a hundred years later (1961) the German psychiatrist and psychoanalyst Hilde Bruch added another of the DSM-5 diagnostic criteria. Bruch described distortion of body image, or dysmorphophobia , as another symptom of anorexia nervosa. Likewise, Bruch pointed out that anorexia nervosa
“It is not a true loss of appetite, but rather a preoccupation with food and feeding.” (Chinchilla, A. 2003).
In 1968, with the publication of the DSM-II, anorexia nervosa appeared for the first time with diagnostic criteria very similar to those of the current DSM-5.
Anorexia for Freud and Lacan.
In his work, Sigmund Freud focuses more on describing in detail the symptoms of his anorexic patients than on typifying the disease. From some of his descriptions it is clear that for Freud anorexia is constituted by a series of symptoms that make up hysteria and that are also related to melancholy, as well as to the oral drive.
For Lacan , in mental anorexia, the symptom gives a substitute satisfaction, instead of a symbolic one, to the object of satisfaction, that is, the mother’s breast. The child struggles with dependence on his mother and develops a negativity in the face of her powerful image, which contains all the primitive objects of desire.
“Through this oppositionism, the almighty mother fails in her power, since it is the child who now exercises dominion: She feeds on nothing. He stands as the master of the mother, who is at the command of her whim. Anorexia is a desire to eat nothing. (Franco, V. 2009).
Epidemiology of anorexia nervosa.
The sex most affected by anorexia nervosa is female , with between 90 and 95% of affected subjects being women.
The average age of onset of this disorder is between 13 and 18 years , although currently there are cases in which it begins before 10 or after 25 years.
In general, the average age of onset is adolescence due to the changes in the body that puberty entails. Currently, living conditions in general and nutritional conditions in particular have improved, advancing puberty and, with it, the onset of anorexia nervosa.
“Regarding social class, although at the beginning of his research it affected mostly girls of upper or middle / upper social class, at present it affects girls of all social classes equally.” (García Camba, E. 2001).
For Ortuño, in 2010, the prevalence of anorexia nervosa in the general population varied between 0.1% and 1%. In adolescents and young women, 1% of this type of population was affected.
Diagnosis of anorexia nervosa.
When setting a starting point, when talking about anorexia nervosa and bulimia nervosa, we will use the diagnostic criteria that the American Psychiatric Association (APA) has set in the 5th edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders) or Diagnostic and Statistical Manual of Mental Disorders.
Diagnosis according to DSM-5.
The DSM-5 establishes three criteria for the diagnosis of anorexia nervosa :
- Restriction of energy intake in relation to needs, leading to significantly low body weight in relation to age, sex, developmental course and physical health. Significantly underweight is defined as a weight that is less than the normal minimum or in children and adolescents, less than the expected minimum.
- Intense fear of gaining weight or gaining weight, or persistent behavior that interferes with weight gain, even at significantly low weight.
- Alteration in the way one perceives one’s own weight or constitution , improper influence of weight or body constitution on self-assessment, or persistent lack of recognition of the severity of current low body weight.
Additionally, DSM-5 describes two types of anorexia nervosa:
-Restrictive type: During the last three months you have not had recurring episodes of bingeing or purging. Weight loss is due to diet, fasting, and / or intense physical exercise.
Binge / Purge Type: During the past three months you have had recurring bouts of bingeing or purging.
Diagnosis of bulimia nervosa.
The DSM-5 establishes five criteria for the diagnosis of bulimia nervosa:
A) Recurring bouts of binge eating . An episode of binge eating is characterized by the following two events:
- Ingestion, in a given period, of an amount of food that is clearly higher than that which most people would ingest in the normal population in a similar period under similar circumstances.
- Feeling of lack of control over what is ingested during the episode.
B) Recurring inappropriate compensatory behaviors to avoid weight gain, such as self-induced vomiting, incorrect use of laxatives, diuretics or other medications, fasting or excessive exercise.
C) Binge eating and inappropriate compensatory behaviors occur on average, at least once a week for three months.
D) Self-assessment is unduly influenced by constitution and body weight.
E) This alteration does not occur exclusively during episodes of anorexia nervosa.
Binge Eating Disorder Diagnosis.
In the DSM-5, Binge Eating Disorder has been described as an independent entity, which has in common with bulimia the presence and frequency of binge eating at least once a week for three months. The main difference is that in Binge Eating Disorder, inappropriate compensatory behaviors do not appear to prevent weight gain and, furthermore, the patient’s self-evaluation is not unduly influenced by the constitution and body weight (it is not a necessary criterion for its diagnosis).
Alexa Clark specializes in Cognitive Behavioral Therapy. She has experience in listening and welcoming in Individual Therapy and Couples Therapy. It meets demands such as generalized anxiety, professional, love and family conflicts, stress, depression, sexual dysfunction, grief, and adolescents from 15 years of age. Over the years, She felt the need to conduct the psychotherapy sessions with subtlety since She understands that the psychologist acts as a facilitator of self-understanding and self-acceptance, valuing each person's respect, uniqueness, and acceptance.